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New York Affidavit of Examining Physician

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AFFIDAVIT (CERTIFICATION) OF EXAMINING PHYSICIAN OR LICENSED PSYCHOLOGIST

SURROGATE'S COURT OF THE STATE OF NEW YORK

COUNTY OF

Proceeding for the Appointment of a Permanent Guardian of the Person and Estate of

An Adult (Name of Respondent) Family File No.

TO THE FAMILY COURT:

File No.

Pursuant to SCPA Article 17-A

STATE OF NEW YORK )

COUNTY OF ) ss.:

I, (Name of Physician or Licensed Psychologist),

Physician Licensed Psychologist ,

being duly sworn, deposes and says:

1. My license number is:

2. My offices are located at

3. My professional knowledge and/or background in the care and treatment of persons with mental retardation developmental disabilities is as follows:

4. I have examined the Respondent on .

I have performed the following tests or evaluations of the Respondent. (Set forth in detail the names of tests and/or evaluations, dates performed and results.)

I have reviewed the following tests or evaluations performed on Respondent. (Set forth in detail the names of tests and/or evaluations, dates performed, results and names of doctors who performed the tests and/or evaluations.)

5. The mental and physical condition of the Respondent is as follows: (Describe in detail.) (Include only the appropriate diagnosis)

6. Mentally Retarded. Based upon the foregoing, it is my conclusion the Respondent is mentally retarded and in my opinion incapable of managing himself and/or his affairs by reason of mental retardation. The nature and degree of the mental retardation is as follows: (Describe)

7. Developmentally Disabled. Based upon the foregoing, it is my conclusion that the Respondent is developmentally disabled and in my opinion he has an impaired ability to understand and appreciate the nature and consequences of decisions, which results in Respondent being incapable of managing himself and/or his affairs by reason of developmental disability, and whose disability is attributable to:

A. Cerebral palsy, which originated before the Respondent attained the age of twenty-two. (Describe, in detail, the nature, degree and origin of the disability.)

B. Epilepsy, which originated before the Respondent attained the age of twenty-two. (Describe, in detail, the nature, degree and origin of the disability).

C. Neurological impairment, which originated before the Respondent attained the age of twenty-two. (Describe, in detail, the nature, degree and origin of the disability.)

D. Autism, which originated before the Respondent attained the age of twenty-two. (Describe, in detail, the nature, degree and origin of the disability.)

E. Traumatic head injury. (Describe, in detail, the nature, degree and origin of the disability.)

F. A condition, which originated before the Respondent attained the age of twenty-two, found to be closely related to mental retardation, because such condition results in similar impairment of general intellectual functioning or adaptive behavior to that of mentally retarded persons. (Describe, in detail, the nature, degree and origin of the disability.)

G. Dyslexia resulting from a disability described in subdivision (a) through (f) or mental retardation which condition originated before the Respondent attained the age of twenty-two. (Describe in detail the nature, degree and origin of the disability or mental retardation.)

8. The condition of the Respondent is permanent in nature or likely to continue indefinitely.

OR The condition of the Respondent is not permanent in nature nor likely to continue indefinitely.

9. There are no circumstances warranting Respondent’s nonappearance at the hearing required by the court. Respondent’s presence at the hearing should be dispensed with because he is medically incapable of being present to the extent that attendance is likely to result in physical harm to the Respondent. (Explain in detail.)

OR

10. Respondent’s presence at the hearing should be dispensed with for the following reasons: (Set forth facts and circumstances which would result in the court finding that the Respondent’s presence at the hearing would not be in his/her best interest.)

OR

11. Based upon the foregoing, it is my conclusion that the Respondent is not capable of understanding and appreciating the nature and consequences of health care decisions, including the benefits and risks of and alternatives to any proposed health care, and of reaching an informed decision in order to promote his own well being. A health care decision may include a decision to withhold or withdraw life-sustaining treatment as defined in subdivision (e) of Section 81.29 of the Mental Hygiene Law.

OR

12. Based upon the foregoing, it is my conclusion that the Respondent is capable of understanding and appreciating the nature and consequences of health care decisions, including the benefits and risks of and alternatives to any proposed health care, and of reaching an informed decision in order to promote his own well being. A health care decision may include a decision to withhold or withdraw life sustaining treatment as defined in subdivision (e) of Section 81.29 of the Mental Hygiene Law.

13. Based upon the foregoing, it is my conclusion that the Respondent has a developmental disability, as defined in Section 1.03 of the Mental Hygiene Law, which includes mental retardation, or results in a similar impairment of general intellectual functioning or adaptive behavior so that such person is incapable of managing himself or herself, and/or his or her affairs by reason of such developmental disability, and that the Respondent is not capable of understanding and appreciating the nature and consequences of health care decisions, including the benefits and risks of and alternatives to any proposed health care, and of reaching an informed decision in order to promote his own well being. A health care decision may include a decision to withhold or withdraw life-sustaining treatment as defined in subdivision (e) of Section 81.29 of the Mental Hygiene Law. Based upon the foregoing, it is my conclusion that the Respondent is capable of understanding and appreciating the nature and consequences of health care decisions, including the benefits and risks of and alternatives to any proposed health care, and of reaching an informed decision in order to promote his own well being. A health care decision may include a decision to withhold or withdraw life sustaining treatment as defined in subdivision (e) of Section 81.29 of the Mental Hygiene Law.

_______________________________________

Signature of Physician/Licensed Psychologist

_______________________________________

Print Name

Sworn to before me this day of , 20 .

____________________________________________

Notary Public

Commission Expires:

(Affix Notary Stamp or Seal)

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What the New York Affidavit of Examining Physician Is

The New York Affidavit of Examining Physician is a sworn, written statement completed by a licensed medical practitioner that records clinical findings from a formal medical examination for use in legal, administrative, or benefits-related proceedings. It ties patient identity to objective observations, test results, diagnoses, and the physician’s professional opinion about functional limitations or fitness. Typical recipients include courts, agencies, insurers, or employers that require contemporaneous medical evidence. The affidavit commonly includes examiner credentials, license number, signature, and a notary acknowledgment or other authentication when required by the receiving authority.

Why this affidavit matters for decisions and records

A clear, properly completed physician affidavit creates an objective medical record that supports adjudication, reduces factual disputes, and documents clinical conditions contemporaneously for courts, insurers, or administrative reviewers.

Why this affidavit matters for decisions and records

Who prepares and requests the affidavit

The New York Affidavit of Examining Physician is prepared and used by different professionals depending on the context; understanding roles helps ensure proper completion and delivery.

  • Physicians and medical examiners: Licensed practitioners who conducted the exam; responsible for accurate clinical findings and legal signature.
  • Attorneys and legal representatives: Request and submit affidavits as evidence in court, guardianship, or disability proceedings.
  • Agencies, insurers, employers: Review affidavits to adjudicate benefits, accommodations, fitness-for-duty, or administrative actions.

Core sections that make an examiner affidavit effective

Well-structured affidavits present identity, clinical detail, professional assessment, and authentication so reviewers can evaluate medical facts efficiently and reliably.

Patient Information

Full legal name, date of birth, contact details, and identifiers. Accurate patient identification prevents administrative errors and ensures the affidavit links to the correct record.

Exam Details

Date, location, reason for exam, procedures performed, and recorded vitals. A clear chronology supports determinations about onset, duration, and causation.

Clinical Findings

Objective observations, physical exam results, and test outcomes documented precisely. Specific findings strengthen the affidavit’s evidentiary value versus general or vague statements.

Diagnosis

Primary and secondary diagnoses with relevant clinical impression or ICD codes when available. The diagnosis section summarizes how findings translate to medical conclusions.

Physician Certification

Examiner name, specialty, office address, license number, and a signed certification attesting to the accuracy of the statements under penalty of law or per agency rules.

Signature & Notary

Signed and dated by the physician; include notary acknowledgement or RON record when the recipient requires notarization for acceptance.

Essential fields to include

Patient Name: Full legal name as on ID
Date of Birth: MM/DD/YYYY format
Exam Date: MM/DD/YYYY of examination
Clinical Findings: Concise, objective medical observations
Physician License: State license number and issuing state
Signature/Notary: Physician signature; notary when required

Step-by-step: preparing and issuing the affidavit

Follow these practical steps to prepare a complete, compliant affidavit ready for notarization and delivery.

  • 01
    Gather IDs: Collect patient ID and relevant medical records before drafting.
  • 02
    Complete Fields: Populate patient, exam, and findings sections accurately.
  • 03
    Sign and Date: Physician signs; include license number and date.
  • 04
    Notarize if required: Obtain notary or RON session per recipient requirements.

Configuring an online workflow for affidavits

Set up an electronic workflow to capture signatures, attachments, and notarization steps consistently when digitizing affidavit handling.

Field Configuration
Authentication Method Email link plus SMS code
Add Notary Field Include RON or notary block
Attachment Requirement Allow PDF and image uploads
Auto-Notify Send completed copy to requestor

Technical requirements for e-submissions and storage

Verify that your e-signature platform supports secure uploads, audit trails, and the file formats required by courts or agencies.

  • File formats: PDF, DOCX accepted
  • Authentication: Email, SMS, or stronger
  • Integrations: EHRs and case management

Typical routing from exam to recipient

A standard document flow moves from exam and documentation to signature, any required notarization, and final delivery to the requesting party.

  • Prepare Document: Populate form fields and attach supporting records.
  • Physician Signature: Signed by examiner with license number included.
  • Notarization: Complete in-person or via RON when allowed.
  • Deliver Final: Send certified copy to court, insurer, or employer.

Timing: common submission triggers and expectations

Deadlines vary by recipient and case type. Confirm required turnaround times with the agency, court, or insurer requesting the affidavit.

Upon Payer Request:

Provide affidavit within the timeframe requested to avoid benefit delays.

Court Deadlines:

Meet filing dates or scheduling orders set by the court clerk.

Employer Requests:

Respond to ADA or fitness-for-duty timelines as specified by employer policy.

Agency Applications:

Include affidavit with initial application when required by the agency.

Record Retention:

Retain originals according to retention policy after submission.

Consequences of incomplete or inaccurate affidavits

Perjury Exposure: Criminal penalty for false statements
Administrative Rejection: Form returned for correction
Claim Denial: Insurance or benefits may be denied
Professional Liability: Physician could face malpractice scrutiny
Evidence Exclusion: Court may exclude unreliable affidavits
Late Submission: Delays in adjudication or benefits

Common preparation mistakes to avoid

  • Omitting notarization or failing to verify that the recipient requires it leads to rejected submissions and processing delays.
  • Providing vague clinical statements without objective findings reduces the affidavit’s utility for adjudicators or insurers assessing functional limitations.
  • Mismatched patient names, incorrect dates, or wrong license numbers create identity verification failures and often require re-execution of the document.
  • Attaching unsupported or illegible records, or failing to label attachments, complicates review and can cause requests for supplemental evidence.

Practical examples of how the affidavit is used

Two typical scenarios illustrate how exam affidavits support legal or administrative outcomes when completed with clear clinical detail and proper authentication.

Disability Claim Support

A treating physician documents objective exam findings and functional limits following a work injury.

  • The affidavit ties symptoms to clinical tests.
  • When paired with objective findings and timely signature, the affidavit strengthens a claimant’s application for short-term disability benefits and reduces requests for supplemental evidence.

Guardianship Evaluation

An examining physician records cognitive exam results and daily living limitations for a guardianship petition.

  • The court relies on contemporaneous medical opinion.
  • A clear, notarized affidavit describing observed deficits and diagnosis helps the court assess capacity and determine appropriate guardianship measures.

Typical eSignature vendor features and starting prices

Comparison of commonly requested eSignature features and published starting prices; signNow is listed first per presentation requirements.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies Varies Varies

Frequently asked questions about affidavits and e-signing

Answers to common questions about signing, notarization, legal validity, corrections, and retention for the New York Affidavit of Examining Physician.


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